Healthcare Provider Details

I. General information

NPI: 1588597348
Provider Name (Legal Business Name): JACK MEHLING
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2026
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1855 STAFFORD RD
PLAINFIELD IN
46168-2338
US

IV. Provider business mailing address

1855 STAFFORD RD
PLAINFIELD IN
46168-2338
US

V. Phone/Fax

Practice location:
  • Phone: 317-839-2088
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number12015029A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: